Virtual Reality for Upper Limb Rehabilitation in Subacute and Chronic Stroke: A Randomized Controlled Trial

Published:February 15, 2018DOI:


      • Combined reinforced feedback in virtual environment with conventional rehabilitation treatment provides clinically meaningful improvements.
      • Effectiveness of reinforced feedback in virtual environment is comparable for patients with ischemic and hemorrhagic stroke.
      • Effectiveness of virtual therapy remains sensitive to time since stroke onset.
      • Effectiveness of virtual therapy does not depend on age and sex.



      To evaluate the effectiveness of reinforced feedback in virtual environment (RFVE) treatment combined with conventional rehabilitation (CR) in comparison with CR alone, and to study whether changes are related to stroke etiology (ie, ischemic, hemorrhagic).


      Randomized controlled trial.


      Hospital facility for intensive rehabilitation.


      Patients (N=136) within 1 year from onset of a single stroke (ischemic: n=78, hemorrhagic: n=58).


      The experimental treatment was based on the combination of RFVE with CR, whereas control treatment was based on the same amount of CR. Both treatments lasted 2 hours daily, 5d/wk, for 4 weeks.

      Main Outcome Measures

      Fugl-Meyer upper extremity scale (F-M UE) (primary outcome), FIM, National Institutes of Health Stroke Scale (NIHSS), and Edmonton Symptom Assessment Scale (ESAS) (secondary outcomes). Kinematic parameters of requested movements included duration (time), mean linear velocity (speed), and number of submovements (peak) (secondary outcomes).


      Patients were randomized in 2 groups (RFVE with CR: n=68, CR: n=68) and stratified by stroke etiology (ischemic or hemorrhagic). Both groups improved after treatment, but the experimental group had better results than the control group (Mann-Whitney U test) for F-M UE (P<.001), FIM (P<.001), NIHSS (P≤.014), ESAS (P≤.022), time (P<.001), speed (P<.001), and peak (P<.001). Stroke etiology did not have significant effects on patient outcomes.


      The RFVE therapy combined with CR treatment promotes better outcomes for upper limb than the same amount of CR, regardless of stroke etiology.


      List of abbreviations:

      CR (conventional rehabilitation), ESAS (Edmonton Symptom Assessment scale), F-M UE (Fugl-Meyer upper extremity scale), NIHSS (National Institutes of Health Stroke Scale), RFVE (reinforced feedback in virtual environment), VRRS (Virtual Reality Rehabilitation System)
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